Laurent Zieleskiewicz

Lung Ultrasound Predicts Interstitial Syndrome and Hemodynamic Profile in Parturients with Severe Preeclampsia

Background:The role of lung ultrasound has never been evaluated in parturients with severe preeclampsia. The authors’ first aim was to assess the ability of lung ultrasound to detect pulmonary edema in severe preeclampsia. The second aim was to highlight the relation between B-lines and increased left ventricular end-diastolic pressures. Methods:This prospective cohort study was conducted in a level-3 maternity during a 12-month period. Twenty parturients with severe preeclampsia were consecutively enrolled. Both lung and cardiac ultrasound examinations were performed before (n = 20) and after delivery (n = 20). Each parturient with severe preeclampsia was compared with a control healthy parturient. Pulmonary edema was determined using two scores: the B-pattern and the Echo Comet Score. Left ventricular end-diastolic pressures were assessed by transthoracic echocardiography. Results:Lung ultrasound detected interstitial edema in five parturients (25%) with severe preeclampsia. A B-pattern was associated to increased mitral valve early diastolic peak E (116 vs. 90 cm/s; P = 0.05) and to increased E/E’ ratio (9.9 vs. 6.6; P < 0.001). An Echo Comet Score of greater than 25 predicted an increase in filling pressures (E/E’ ratio >9.5) with a sensitivity and specificity of 1.00 (95% CI, 0.69 to 1.00) and 0.82 (95% CI, 0.66 to 0.92), respectively. Conclusions:In parturients with severe preeclampsia, lung ultrasound detects both pulmonary edema and increased left ventricular end-diastolic pressures. The finding of a B-pattern should restrict the use of fluid. However, these preliminary results are associations from a single sample. They need to be replicated in a larger, definitive study.

Lung ultrasound‐guided management of acute breathlessness during pregnancy

Lung ultrasonography is a standard tool in the intensive care unit and in emergency medicine, but has not been described in the particular setting of the labour ward. During pregnancy, acute respiratory failure and pulmonary oedema are not uncommon life‐threatening events. We present two case reports outlining the potential of lung ultrasonography in parturients. In case 1, lung ultrasonography allowed early diagnosis and treatment of acute dyspnoea in a parturient admitted for suspected asthma exacerbation. Lung ultrasonography revealed a ‘B‐pattern’ of vertical lines radiating into the lung tissue, indicating severe pulmonary oedema complicating previously undiagnosed pre‐eclampsia. In case 2, a pre‐eclamptic patient was managed with combined transthoracic echocardiography and lung ultrasonography. The accuracy of lung ultrasonography in detecting interstitial oedema at a pre‐clinical stage allowed adequate fluid resuscitation in this patient who had a high risk of alveolar pulmonary oedema. We believe that these cases strongly support the prospective validation of lung ultrasound for management of lung disorders in pregnant women.

Gestion des voies aériennes supérieures en fin d’accouchement : enquête de pratique ☆

OBJECTIVE To describe the airway management during general anaesthesia performed at the end of labour. STUDY DESIGN Observational retrospective study in a French university obstetrical unit. PATIENTS AND METHODS All parturients who underwent general anaesthesia for manual removal of the placenta or instrumental delivery were included. Demographic data, anaesthesia management, indication and duration of anaesthesia were recorded. Incidents as vomiting, a drop in oxygen saturation of five points or more, aspiration and difficult endotracheal intubation were investigated. RESULTS Among 111 parturients with inclusion criteria, the rate of tracheal intubation was 5%. The duration of anaesthesia ranged from five to 60 minutes (mean duration: 16 min). No incident was recorded within the methodological limits of this retrospective study. CONCLUSION There is a major discrepancy between guidelines and clinical practice in our unit concerning systematic tracheal intubation during general anaesthesia performed at the end of labour. A national survey is in process to confirm these results.

Influence of Diaphragmatic Motion on Inferior Vena Cava Diameter Respiratory Variations in Healthy Volunteers

Background:The collapsibility index of inferior vena cava (cIVC) is widely used to decide fluid infusion in spontaneously breathing intensive care unit patients. The authors hypothesized that high inspiratory efforts may induce false-positive high cIVC values. This study aims at determining a value of diaphragmatic motion recorded by echography that could predict a high cIVC (more than or equal to 40%) in healthy volunteers. Methods:The cIVC and diaphragmatic motions were recorded for three levels of inspiratory efforts. Right and left diaphragmatic motions were defined as the maximal diaphragmatic excursions. Receiver operating characteristic curves evaluated the performance of right diaphragmatic motion to predict a cIVC more than or equal to 40% defining the best cutoff value. Results:Among 52 included volunteers, interobserver reproducibility showed a generalized concordance correlation coefficient (&rgr;c) above 0.9 for all echographic parameters. Right diaphragmatic motion correlated with cIVC (r = 0.64, P < 0.0001). Univariate analyses did not show association between cIVC and age, sex, weight, height, or body mass index. The area under the receiver operating characteristic curves for cIVC more than or equal to 40% was 0.87 (95% CI, 0.81 to 0.93). The best diaphragmatic motion cutoff was 28 mm (Youden Index, 0.65) with sensitivity of 89% and specificity of 77%. The gray zone area was 25 to 43 mm. Conclusions:Inferior vena cava collapsibility is affected by diaphragmatic motion. During low inspiratory effort, diaphragmatic motion was less than 25 mm and predicted a cIVC less than 40%. During maximal inspiratory effort, diaphragmatic motion was more than 43 mm and predicted a cIVC more than 40%. When diaphragmatic motion ranged from 25 to 43 mm, no conclusion on cIVC value could be done.

Determination of a cut-off value of antral area measured in the supine position for the fast diagnosis of an empty stomach in the parturient A prospective cohort study

BACKGROUND Ultrasound measurement of the antral cross-sectional area of the stomach, performed in the supine position, has been described for preoperative assessment of gastric content in the adult, but, to date, no study has determined the cut-off value of the antral area for the diagnosis of an empty stomach in the parturient. Nevertheless, previous studies in parturients have reported that the use of a simple qualitative grading scale (0 to 2) was reliable for the estimation of the gastric fluid volume. However, this qualitative grading score requires turning the parturient into the right lateral decubitus position for the ultrasound examination, something which may not be easily feasible, particularly in the case of an obstetric emergency. OBJECTIVE To calculate the cut-off value of the antral area, measured in the supine position during established labour, for the diagnosis of ‘empty’ stomach. DESIGN A prospective cohort study. SETTING Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France. PATIENTS Seventy-three women in established labour. INTERVENTIONS For each parturient, ultrasound assessment of gastric contents was performed in the supine and right lateral decubitus position and scored 0 to 3 on a qualitative grading scale. This assessment was followed by ultrasound measurement of the antral cross-sectional area in both the supine and right lateral positions. MAIN OUTCOME MEASURES To assess the performance of the antral area measured in the supine position for the diagnosis of an ‘empty’ stomach (gastric antrum grade 0), a receiver operating characteristic curve was plotted, and the area under the receiver operating characteristic curve was calculated. RESULTS Data from 73 women were analysed. For the diagnosis of grade 0, the cut-off value for the antral area measured in the supine position was 381 mm2 (sensitivity, 81%; specificity, 76% and negative predictive value, 80%). CONCLUSION With a parturient lying in the supine position, a single assessment of the antral cross-sectional area may be used for the fast diagnosis of an empty stomach. This tool could be useful in assessing the risk of aspiration for parturients who require emergency anaesthesia during labour.

Hypoxia-inducible factor (HIF1α) gene expression in human shock states

IntroductionHypoxia-inducible factor-1 (HIF1) controls the expression of genes involved in the cellular response to hypoxia. No information is available on its expression in critically ill patients. Thus, we designed the first clinical study in order to evaluate the role of HIF1α as a prognosis marker in patients suffering from shock.MethodsFifty consecutive adult patients with shock and 11 healthy volunteers were prospectively enrolled in the study. RNA was extracted from whole blood samples and expression of HIF1α was assessed over the first four hours of shock. The primary objective was to assess HIF1α as a prognostic marker in shock. Secondary objectives were to evaluate the role of HIF1α as a diagnostic and follow-up marker. Patient survival was evaluated at day 28.ResultsThe causes of shock were sepsis (78%), hemorrhage (18%), and cardiac dysfunction (4%). HIF1α expression was significantly higher in the shock patients than in the healthy volunteers (121 (range: 72-168) versus 48 (range: 38-54) normalized copies, P <0.01), whatever the measured isoforms. It was similar in non-survivors and survivors (108 (range 84-183) versus 121(range 72-185) normalized copies, P = 0.92), and did not significantly change within the study period.ConclusionsThe present study is the first to demonstrate an increased expression of HIF1α in patients with shock. Further studies are needed to clarify the potential association with outcome. Our findings reinforce the value of monitoring plasma lactate levels to guide the treatment of shock.

Pré-éclampsie sévère et hémorragie post-partum: apport de l’échographie « corps entier »

PURPOSE Management of severe pre-eclamptic patients is a challenge for the staff on obstetrical wards. We demonstrate that ultrasound applied to several organs performed at a patients bedside gave the information required for the patients management, without the need to transfer her to the radiology department or to call external consultants. CLINICAL FEATURES A 29-yr-old severely pre-eclamptic patient with HELLP syndrome (hemolysis, cytolysis, thrombopenia) presented, in the post-partum period, with an occult uterine hemorrhage diagnosed with bedside abdominal/pelvic ultrasound. Ultrasound was also used to insert a central venous catheter. After undergoing a hysterectomy to control hemorrhage and receiving activated factor VII, the patient recovered uneventfully. Hemodynamic management was optimized non-invasively using pulmonary and cardiac ultrasound, when the patient developed hemorrhagic shock followed by pulmonary edema. Volume replacement was guided by cardiac ultrasound findings, and we were able to detect incipient interstitial pulmonary edema and follow its course using pulmonary ultrasound. CONCLUSION Practitioners must be aware of the role of whole-body ultrasound in the diagnosis and treatment of complex, multi-organ conditions such as pre-eclampsia. Moreover, ultrasound helps in the management of global hemodynamics. The training of anesthesiologists in a variety of ultrasound techniques should be encouraged.

Implementation of lung ultrasound in polyvalent intensive care unit: Impact on irradiation and medical cost.

OBJECTIVE To determine the effect of implementing a daily lung ultrasound round on the number of chest radiographs and chest computed tomography (CT) scans in a polyvalent intensive care unit (ICU). STUDY DESIGN Retrospective study comparing two consecutive periods. PATIENTS All patients hospitalized for longer than 48 hours in a polyvalent ICU. METHODS Implementation of a daily lung ultrasound round after a short educational program. The number of chest radiographs and chest CT scans and the patient outcome were measured before (group PRE) and after (group POST) the implementation of a daily lung ultrasound round. RESULTS No demographic difference was found between the two groups, with the exception of a higher severity score in the group POST. For each ICU stay, the number of chest radiographs was 10.3 ± 12.4 in the group PRE and 7.7 ± 10.3 in the group POST, respectively (P<0.005) The number of chest CT scans was not reduced in the group POST, as compared with the group PRE (0.5 ± 0.7 CT scan/patient/ICU stay versus 0.4 ± 0.6 CT scan/patient/ICU stay, P=0.01). The ICU mortality was similar in both groups (21% versus 22%, P=0.75) CONCLUSION: The implementation of a daily lung ultrasound round was associated with a reduction in radiation exposure and medical cost without altering patient outcome.

[Upper airway management in obsterics: results of a French survey].

Au redacteur en chef, La realisation d’une anesthesie generale (AG) chez une parturiente est associee a un risque significatif d’intubation orotracheale difficile et d’inhalation. Toute parturiente audela de 16 a 21 semaines d’amenorrhee doit etre consideree comme a risque d’estomac plein. Par consequent, les experts d’anesthesie obstetricale recommandent l’intubation orotracheale systematique en cas d’AG. Conscientes de ce risque de morbidite et de mortalite maternelles imputable a l’anesthesie, les societes savantes, notamment l’American Society of Anesthesiologists et la Societe francaise d’anesthesie et de reanimation ont emis des recommandations sur la gestion des voies aeriennes superieures et sur la prophylaxie de l’inhalation en obstetrique. Notre objectif a ete de verifier l’application de ces recommandations sur le terrain. En 1996, une enquete francaise ne rapportait que 8% d’intubation orotracheale lors des AG pour manipulations uterines apres l’accouchement. Au Canada, une analyse des pratiques realisee en 1998 montrait qu’environ 80% des AG pour revision uterine etaient realisees sans intubation orotracheale. Depuis pres de 10 ans, aucune autre etude n’a aborde ce sujet. Nous avons donc realise une evaluation des pratiques concernant la prise en charge des voies aeriennes superieures en obstetrique en France au moyen d’un questionnaire national anonyme disponible en ligne du 10 mai au 10 novembre 2007. Quatre-cent-vingt anesthesistes ont repondu a ce questionnaire. De ce nombre, 58% declaraient disposer pour l’intubation orotracheale d’un capnographe; 86%, d’un chariot d’intubation difficile; et 71%, d’un algorithme de prise en charge de l’intubation orotracheale difficile. Quatre-vingt-six pour cent des participants a cette enquete declaraient prescrire une chimioprophylaxie de l’inhalation avant l’AG. Ils n’etaient que 24% a declarer pratiquer une intubation orotracheale systematique en cas de revision uterine ou delivrance artificielle du placenta, et ils etaient 45% a dire utiliser l’intubation systematique lors de manœuvres instrumentales. En cas d’intubation orotracheale, la succinylcholine etait utilisee par 82% des anesthesistes interroges. Les suivis des recommandations sur la prise en charge des voies aeriennes superieures et la chimioprophylaxie de l’inhalation sont relativement satisfaisants. Deux exceptions restent a signaler : l’utilisation du capnographe et la pratique de l’intubation orotracheale systematique lors des AG en fin d’accouchement. Alors que l’intubation orotracheale est quasi systematique en France lors des cesariennes sous AG, la pratique est beaucoup moins generalisee lors des AG realisees apres l’accouchement. Ce resultat confirme ceux retrouves dans les etudes precedentes. Le taux d’intubation orotracheale n’etait que de 5% dans une enquete recente realisee au sein de notre structure. Plusieurs hypotheses sont a discuter pour expliquer cette discordance. Le rapport benefice / risque de chaque technique anesthesique, i.e. ventilation spontanee au masque versus intubation orotracheale, n’est pas percu de facon consensuelle entre les experts et les anesthesistes exercant dans les maternites. Par ailleurs, seuls 58% des praticiens declaraient disposer d’un capnographe alors que celui-ci est recommande par l’ensemble des societes pour la gestion des voies aeriennes superieures en anesthesie. Ce resultat L. Zieleskiewicz, MD J. P. Bellefleur, MD (&) M. Leone, MD, PhD Hopital Nord, Assistance Publique-Hopitaux de Marseille, Marseille, France e-mail: jeanpierre.bellefleur@ap-hm.fr

Prise en charge des voies aériennes supérieures en obstétrique: enquête française de pratique

Au redacteur en chef, La realisation d’une anesthesie generale (AG) chez une parturiente est associee a un risque significatif d’intubation orotracheale difficile et d’inhalation. Toute parturiente audela de 16 a 21 semaines d’amenorrhee doit etre consideree comme a risque d’estomac plein. Par consequent, les experts d’anesthesie obstetricale recommandent l’intubation orotracheale systematique en cas d’AG. Conscientes de ce risque de morbidite et de mortalite maternelles imputable a l’anesthesie, les societes savantes, notamment l’American Society of Anesthesiologists et la Societe francaise d’anesthesie et de reanimation ont emis des recommandations sur la gestion des voies aeriennes superieures et sur la prophylaxie de l’inhalation en obstetrique. Notre objectif a ete de verifier l’application de ces recommandations sur le terrain. En 1996, une enquete francaise ne rapportait que 8% d’intubation orotracheale lors des AG pour manipulations uterines apres l’accouchement. Au Canada, une analyse des pratiques realisee en 1998 montrait qu’environ 80% des AG pour revision uterine etaient realisees sans intubation orotracheale. Depuis pres de 10 ans, aucune autre etude n’a aborde ce sujet. Nous avons donc realise une evaluation des pratiques concernant la prise en charge des voies aeriennes superieures en obstetrique en France au moyen d’un questionnaire national anonyme disponible en ligne du 10 mai au 10 novembre 2007. Quatre-cent-vingt anesthesistes ont repondu a ce questionnaire. De ce nombre, 58% declaraient disposer pour l’intubation orotracheale d’un capnographe; 86%, d’un chariot d’intubation difficile; et 71%, d’un algorithme de prise en charge de l’intubation orotracheale difficile. Quatre-vingt-six pour cent des participants a cette enquete declaraient prescrire une chimioprophylaxie de l’inhalation avant l’AG. Ils n’etaient que 24% a declarer pratiquer une intubation orotracheale systematique en cas de revision uterine ou delivrance artificielle du placenta, et ils etaient 45% a dire utiliser l’intubation systematique lors de manœuvres instrumentales. En cas d’intubation orotracheale, la succinylcholine etait utilisee par 82% des anesthesistes interroges. Les suivis des recommandations sur la prise en charge des voies aeriennes superieures et la chimioprophylaxie de l’inhalation sont relativement satisfaisants. Deux exceptions restent a signaler : l’utilisation du capnographe et la pratique de l’intubation orotracheale systematique lors des AG en fin d’accouchement. Alors que l’intubation orotracheale est quasi systematique en France lors des cesariennes sous AG, la pratique est beaucoup moins generalisee lors des AG realisees apres l’accouchement. Ce resultat confirme ceux retrouves dans les etudes precedentes. Le taux d’intubation orotracheale n’etait que de 5% dans une enquete recente realisee au sein de notre structure. Plusieurs hypotheses sont a discuter pour expliquer cette discordance. Le rapport benefice / risque de chaque technique anesthesique, i.e. ventilation spontanee au masque versus intubation orotracheale, n’est pas percu de facon consensuelle entre les experts et les anesthesistes exercant dans les maternites. Par ailleurs, seuls 58% des praticiens declaraient disposer d’un capnographe alors que celui-ci est recommande par l’ensemble des societes pour la gestion des voies aeriennes superieures en anesthesie. Ce resultat L. Zieleskiewicz, MD J. P. Bellefleur, MD (&) M. Leone, MD, PhD Hopital Nord, Assistance Publique-Hopitaux de Marseille, Marseille, France e-mail: jeanpierre.bellefleur@ap-hm.fr